Sponsor

You are sponsoring

Sponsor Amount: $ (e.g. 180.00)

Personal Information

First Name: *

Last Name: *

Company Name:

Address: *

City: *

State: *

Zip Code: *

Country: *

Phone Number: *

Cell Phone:

Email Address: *

Payment Details

Credit Card

Card Number: *

Exp. Month: *

Exp. Year: *

Security Code: *

Additional Comments:

Please mail a receipt to the address above (in addition to the receipt I will receive via email).

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Please add the following comment to the ticker on 's personal page. (eg: In honor of xxx)

Please display me as anonymous on the ticker at 's personal page.

Only enter this field if you were told to do so by a staff member.

All donations charges will be made via The 100 Ride.
The 100 Ride is a non-profit 501c3 organization.